Importance of Safety-netting
Safety netting is crucial to ensure patients and parents have a clear plan to return when discharged if any concerning symptoms arise. A patient’s condition can change rapidly, and while they may be fit for discharge now, their health could deteriorate before it improves.
Children are resilient and are generally fit and healthy. They may present to the emergency department with a cough, cold or fever. We tend to watch and wait, offer some paracetamol or ibuprofen if necessary, and if they improve and are tolerating fluids, we are happy to send them home. Alternatively, they may have fallen off the monkey bars, so we offer some painkillers, do an X-ray to confirm the fracture, and apply a cast. Then, they are safe for discharge.
Most children are generally well and can be sent home directly from the ED with appropriate safety netting and follow-up. Some may need admission to the paediatric short-stay unit, a unit in the emergency department where patients can stay for up to 24 hours. By then, it is easier to determine whether they are safe for discharge or need to be admitted to the wards.
A common admission to SSU is viral-induced wheeze or asthma, when salbutamol use needs to be stretched to an appropriate period of time before the child is safe for discharge. Alternatively, the child may have poor oral intake with vomiting or diarrhoea, so they are given anti-emetics and monitored to ensure they can tolerate some fluids before discharge.
We often provide the same generic safety netting advice on discharge. My general spiel goes like this:
“If your child has had less than 50% of their normal fluid intake in a 24-hour period, if they have had less than 3-4 wet nappies in a 24-hour period, if they have increased work of breathing (including tracheal tug, intercostal/subcostal recessions, head bobbing), if they are lethargic or if you are concerned, please bring them back to the emergency department and/or seek medical attention.”
Let’s break it down:
Less than 50% of normal fluid intake in a 24-hour period
Children who are sick generally don’t eat or drink, so dehydration is a legitimate concern. Many children will have decreased oral intake and often not eat any solid food – but it is important to explain to parents that it is normal for children to be off their food when they are sick and what we, as the medical team, are concerned about, is their fluid intake.
Parents should monitor their children’s fluid intake—any type of fluid, including water, juices, icy poles, and ice cream (sick kids are allowed all of these, whatever they can tolerate!).
If a person’s fluid intake is less than 50% of normal in a 24-hour period, they are at risk of becoming dehydrated, and this is when they should seek medical attention.
Less than 3-4 wet nappies in a day
We’ve already seen how important hydration is. One way we can measure hydration in children is the number of times they wee or the number of wet nappies they produce in a day.
Variations of this in toilet-trained children are “Going to the toilet less than 3-4 times a day”, or some also prefer “Going to the toilet less than 50% of normal”.
Increased work of breathing
This is important in children with respiratory infections. Even when a child is safe to send home, it is still important to let parents know when they should be concerned and return to the hospital.
Signs to look out for include tracheal tug, intercostal and subcostal recessions, head bobbing, increased respiratory rate, nasal flaring, cyanosis and nasal flaring. Explain these signs, and perhaps show the parents so can present to the emergency department if needed.
For bronchiolitis, if the child is on day four of the illness, reassure the parents that deterioration is unlikely as the peak severity has usually passed.
However, if the child is only on day one of the illness and is still safe for discharge, inform the parents that the condition may worsen. Advise them to return to the emergency department if they notice any concerning signs.
Lethargy
Children are usually full of energy and play, are interested, and interact with the environment around them. However, this is very different when sick, and parents are very good at telling us when their child is more lethargic than usual.
If children are lethargic and floppy, it can be a sign that they are very sick, and parents should bring them back to the hospital if this does occur.
Parental concern
Arguably, this is one of the most important advice we give parents.
It is very important to let the parents know that they are welcome back in the paediatric emergency department whenever they have any concerns about their child, regardless of their concerns.
Parents know their children better than any clinician and understand what is normal for their child and when they should be concerned.
It may seem obvious that parents would bring their child back to the hospital if worried, but some may hesitate. They might think that since a doctor has already evaluated and sent their child home, there is no new help available, or they may feel embarrassed about returning for the same illness. However, this is not the case.
Parents are always encouraged to return to the emergency department if concerned. The child’s condition may have changed, requiring further support or observation. A second visit might prompt a reassessment of the diagnosis or the need for more monitoring. If a child presents to the emergency department for a third time, it typically raises concern among clinicians, necessitating a senior review, extended observation, and possibly admission.
Other things I sometimes include in my safety netting, depending on the presentation, are:
If you are required to use salbutamol more often than every 3 hours
Many children present with viral-induced wheeze from a respiratory infection or asthma and require salbutamol. Typically, after initial treatment, we stretch the dosing interval to every three hours before considering discharge.
We advise parents to watch for signs of increased work of breathing and to administer the inhaler when they notice these signs. If their child needs salbutamol more frequently than every three hours due to increased work of breathing, this indicates the need for closer monitoring and a return to the emergency department.
Providing parents with an asthma action plan is crucial, as it gives them clear, written instructions on what symptoms to watch for, when to be concerned, and how to manage an asthma attack.
(After putting on a cast, especially a full plaster) If you feel any tingling or numbness, if you lose sensation, can’t move your fingers or are in significant pain, or if your fingers turn pale or blue.
For children with limb injuries requiring a cast, particularly a full plaster cast, inform parents about red flags indicating that the cast may be too tight. These signs include increased pain, swelling, numbness, tingling, or discolouration of the fingers or toes.
Immediate medical attention is needed to cut the cast and relieve pressure to restore proper blood flow. A plaster check by a healthcare professional 24 hours after application is recommended to ensure no complications develop.
Before discharge, ensure all patients are appropriately safety-netted. Include any advice in the discharge summary so parents can refer to it later if needed. Providing a relevant handout about the condition can also help. Written information is especially helpful because parents are often worried and stressed while in the hospital, making it difficult to retain all the verbal information. A written handout allows them to review the information at their own pace and refer to it as needed in the future.
I can still remember a couple of times when a patient that I had previously discharged a few days ago had re-presented back to the emergency department, and how awful I felt thinking that I had failed to give them the correct treatment and that they had re-presented due to this.
However, one piece of advice I was given by a senior doctor resonated with me:
“When a patient has re-presented back to the emergency department, this does not mean that they were a failed discharge or that you have failed to correctly treat them, in fact, it actually means that you have successfully safety-netted them so that the parents were aware of when to come back to the emergency department”
As an intern in the paediatric emergency department and having done many short-stay rounds with many different consultants, I have noticed that each clinician’s perception of risk is slightly different, and the level of risk that they take is also different.
Each consultant I have worked with has had so much experience (I hope I am slowly absorbing by spending more time with them), but their training and experiences have all been slightly different. Of course, they can tell who the sick kids who need resus and be admitted to PICU are, and of course, they can also tell the kids who need a bit of observation but are otherwise okay to be discharged home.
The middle group of children is treated differently—not incorrectly, just differently. General treatment principles are the same, but some senior doctors may introduce nasogastric fluids earlier than others, while some may choose to offer a trial of fluids first before introducing the NGT. Some clinicians observe children longer than others, and some may have a lower threshold for intervention and investigations like blood gas. This depends on the individual training and experiences og each person has gone through during their years as a doctor.
For each patient that presents to the emergency department, the consultants take a calculated risk, weighing the risks and benefits of certain investigations (e.g. radiation for a scan or distress for a cannula) before deciding. It is important to consider the level of risk parents are comfortable with and involve them in decision-making. Discussing the pros and cons of various options and understanding their preferences helps ensure they are part of the care plan.
After chatting with some of the consultants in my department about how they view risk, it was evident that each consultant approaches risk differently and has different discharge thresholds.
Two consultants may have differing opinions on how to treat one patient. One consultant may be more comfortable sending them home, while the other would like to monitor the patient further. Even during the same shift, doctors may become more risk-averse closer to the end of the shift as they may be unconsciously aware that they are more tired and more prone to making mistakes.
Many parents believe that, as doctors, we know everything – but we don’t.
If I had a crystal ball that would be able to tell me exactly which child would deteriorate and require admission and which child is safe to send home, my job would be a lot easier! It can be difficult to predict what will happen next with a child, but seeing many children in similar situations gives us clues about whether a particular child is likely to deteriorate or can be safely sent home. While we cannot guarantee that a child will not get worse after discharge, it is also not feasible to keep all children in the hospital indefinitely. Senior doctors use their experience and calculated risks to make these decisions. This is where the importance of safety-netting comes in. Even if we do not expect the child to deteriorate, parents will know when to bring them back to the hospital for reassessment if needed.
To add an extra level of safety, some consultants advise parents to take their child to a GP or primary care centre 24-48 hours after discharge for a check-up. This ensures the child is not getting worse and provides reassurance for both the parents and the doctor. Although the child may be improving and safe for discharge, predicting what will happen next is difficult. A follow-up visit with the GP helps ensure appropriate monitoring and minimizes the risk of deterioration.
References
Government VS. Guidelines for emergency department short stay units. Victoria: Victoria State Government – Health and Human Services; 2017.
